Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Surfactant supported chitosan for efficient removal of Cr(VI) and anionic food stuff dyes from aquatic solutions

Abstract In order to develop a novel and cost-effective adsorbent with outstanding adsorption capacity and excellent recyclability for anionic pollutants, the chitosan-modified cetyltrimethylammonium bromide sorbent (CS@CTAB) was fabricated. Fourier-transform infrared spectroscopy, N2 adsorption–desorption isotherm, elemental analysis, Thermogravimetric analysis, X-ray diffraction, and Scanning electron microscopy have been applied to evaluate both raw and surfactant modified chitosan (CS@CTAB). Azorubine, Sunset Yellow, and hexavalent chromium were used to study the adsorption behavior of CS@CTAB under various parameters such as adsorbent dose, initial dye and metal ion concentration, contact time, and temperature. Adsorption equilibrium, kinetics models and thermodynamic parameters were investigated. The adsorption isotherm fitted well with the Langmuir isotherm model, with a maximum adsorption capacity of 492.6 mg/g, 492.6 mg/g, and 490.196 mg/g for Azorubine, Sunset Yellow, and Hexavalent Chromium, respectively. The kinetic studies showed that the pseudo-second-order model provided a better correlation between experimental data. Furthermore, the calculated thermodynamic parameters confirmed that the adsorption of Cr(VI), E110, and E122 by CS@CTAB material is a spontaneous and exothermic process. The fabricated CS@CTAB adsorbent was employed for the efficient elimination of Azorubine, Sunset Yellow, and hexavalent chromium from real water samples, synthetic mixtures, and colored soft drinks, with a percentage of recovery of ~ 96%. The plausible adsorption mechanisms of Azorubine, Sunset Yellow, and hexavalent chromium on the surface of CS@CTAB are elucidated. The adsorption anticipated to be due to electrostatic interaction and hydrogen bond formation for hexavalent chromium; while the adsorption of Azorubine and Sunset Yellow, was assumed to be due to electrostatic interaction, hydrogen bonding, and n-π interaction. Finally, the study demonstrates the efficiency of CS@CTAB for the removal of anionic species from several samples, including natural water and colored beverages

Narrative role of vitamin D receptor with osteoporosis and obesity in a sample of Egyptian females: a pilot study

Abstract Background Vitamin D receptor (VDR) is known as one of the cellular regulators for several metabolic pathways indicating its pivotal role in the pathological pathway of numerous diseases. Considering the high frequency of osteoporosis and obesity among women, the current study aimed to explore the prospective assembly of the most frequent two VDR loci, single nucleotide polymorphism SNPs rs731236 (TaqI) and rs7975232 (ApaI) with a genetic predisposition to osteoporosis (skeletal) and obesity (chronic non-skeletal disorders), in Egyptian women. This was a cross-sectional study, including 97 Egyptian females (25–65 years), randomly chosen, from all employees and workers of the National Research Centre, Egypt. Anthropometric measurements (weight, height, BMI), dual-energy X-ray absorptiometry (DEXA), and molecular genetic analysis were done. Results The variation of ApaI genotype between the normal and osteoporotic groups denotes a remarkable association of the homozygote ApaI genotype with osteoporosis risk. Among the normal weight group, bone mineral density (BMD) was significantly associated with TaqI VDR gene polymorphism as the presence of the heterozygote genotype was accompanied with higher BMD while the homozygote one was detected with lower BMD. Also, TaqI VDR gene polymorphism was significantly associated with BMI when participants were divided according to the presence of osteoporosis; increased BMI was expressed in the non-osteoporotic women group carrying the homozygote genotype of Taq I VDR gene while the presence of the heterozygote genotype (TaqI) in the osteoporotic group was associated with increased BMI. Conclusions The heterozygote TaqI genotype is protective against the osteoporosis phenotype and accompanied with increased BMI among osteoporotic women, while the homozygote ApaI genotype has a significant association with osteoporosis risk

Association of some dietary ingredients, vitamin D, estrogen, and obesity polymorphic receptor genes with bone mineral density in a sample of obese Egyptian women

Abstract Background Although many environmental factors play an important role in bone mass density (BMD) variation, genetic influences account for 60–85% of individual variance. The aim of this study was to find the interaction between some dietary ingredients, vitamin D, estrogen, and obesity polymorphic receptor genes, among a sample of obese Egyptian women. This was a cross sectional study included 97 women (aged 25–60 years). Data on anthropometry, dietary intake, BMD, biochemical, and genetic analyses were collected. Results Osteoporosis was high among women had dominant Taq1 vitamin D receptor gene while osteoporosis was less common among the homozygous Apa1 receptor gene women. Both genes in their two forms did not show any effect on serum vitamin D. Heterozygous types of osteoporotic women carried both genes revealed a slight but significant decrease in level of serum calcium. Xba1 estrogen receptor gene was identified only in a homozygous type while the heterozygous Pvu11 estrogen receptors gene has been identified among both osteoporotic and non-osteoporotic women, this gene was associated with higher BMI in both groups compared to the homozygous receptor gene. Mutant types of genotype FTOrs99 and FTOrs80 obesity receptors genes were less common (4.44%, 11%) among participants. Both of these genes were associated with the highest value of BMI and caloric daily intake, fat, and saturated fatty acid that were more prominent among osteoporotic women. Conclusion There is significant association between vitamin D, estrogen, obesity receptors genes, special nutrients, and osteoporosis. Increased BMI, calories, and fat intake lead to rise of genetic predisposition and susceptibility to osteoporosis

Evaluation of circulating insulin-like growth factor-1, heart-type fatty acid-binding protein, and endotrophin levels as prognostic markers of COVID-19 infection severity

Abstract Background Coronavirus Disease 2019 (COVID-19) is a worldwide pandemic challenge spreading enormously within a few months. COVID-19 is characterized by the over-activation of the immune system causing cytokine storm. Insulin-like growth factor-1 (IGF-1) pathway can regulate the immune response via interaction with various implicated cytokines. Heart-type fatty acid-binding protein (H-FABP) has been shown to promote inflammation. Given the fact that coronavirus infections induce cytokines secretion leading to inflammatory lung injury, it has been suggested that H-FABP levels are affected by COVID-19 severity. Moreover, endotrophin (ETP), the cleavage product of collagen VI, may be an indicator of an overactive repair process and fibrosis, considering that viral infection may predispose or exacerbate existing respiratory conditions, including pulmonary fibrosis. This study aims to assess the prognostic capacity of circulating IGF-1, HFABP, and ETP, levels for COVID-19 severity progression in Egyptian patients. Methods The study cohort included 107 viral RNA-positive patients and an equivalent number of control individuals with no clinical signs of infection. Clinical assessments included profiling of CBC; serum iron; liver and kidney functions; inflammatory markers. Circulating levels of IGF-1; H-FABP, and ETP were estimated using the corresponding ELISA kits. Results No statistical difference in the body mass index was detected between the healthy and control groups, while the mean age of infected patients was significantly higher (P = 0.0162) than the control. Patients generally showed elevated levels of inflammatory markers including CRP and ESR concomitant with elevated serum ferritin; D dimer and procalcitonin levels, besides the COVID-19 characteristic lymphopenia and hypoxemia were also frequent. Logistic regression analysis revealed that oxygen saturation; serum IGF-1, and H-FABP can significantly predict the infection progression (P < 0.001 each). Both serum IGF-1 and H-FABP as well as O2 saturation showed remarkable prognostic potentials in terms of large AUC values, high sensitivity/specificity values, and wide confidence interval. The calculated threshold for severity prognosis was 25.5 ng/mL; 19.5 ng/mL, 94.5, % and for IGF-1, H-FABP, and O2 saturation; respectively. The calculated thresholds of serum IGF-1; H-FABP, and O2 saturation showed positive and negative value ranges of 79–91% and 72–97%; respectively, with 66–95%, 83–94% sensitivity, and specificity; respectively. Conclusion The calculated cut-off values of serum IGF-1 and H-FABP represent a promising non-invasive prognostic tool that would facilitate the risk stratification in COVID-19 patients, and control the morbidity/mortality associated with progressive infection

Survey on Implementation of One Health Approach for MERS-CoV Preparedness and Control in Gulf Cooperation Council and Middle East Countries

In 2015, a One Health Working Group was established in Qatar to conduct a survey in the Gulf Cooperation Council countries, Egypt, and Jordan to monitor preparedness of public health and veterinary health authorities in response to the Middle East respiratory syndrome coronavirus epidemic. All but 1 country indicated they established joint One Health policy teams for investigation and response. However, the response to the questionnaires was largely limited to veterinary authorities. Critical barriers and limitations were identified. National and regional leaders, policy makers, and stakeholders should be prompted to advocate and enhance adoption of the One Health framework to mitigate the risk for Middle East respiratory syndrome and other emerging zoonotic diseases